Summary

To mobilize the above knowledge into clinical practice further research is needed to determine: 1) the influence of cushion type on muscle and skin perfusion; 2) the effects of friction and shear on skin and muscle perfusion and pressure during use of recline and/or tilt and/or standing; 3) the influence of postural deformities/tendencies on perfusion levels on both of the above and; 4) the effects of duration of large amplitudes of position changes within participants’ regular daily routines of position changes.

There is level 4 (from one case series study; Boninger et al. 2002) evidence that the semicircular and double-loop-over propulsion wheelchair stroke patterns reduce cadence and time spent in each phase of propulsion, thus using these patterns may reduce the risk of median nerve injury.

There is level 4 (from two case series studies; Richter et al. 2007; Raina et al. 2012b) evidence that there is no difference in hand rim biomechanics during propulsion between the four stroke patterns. However, there is also level 4 (from two case series studies; Boninger et al. 2002; Kwarciak et al. 2012) evidence that the semicircular and double-loop-over propulsion stroke patterns offer the best combination of biomechanics for propulsion.

There is level 4 (from one case series study by Raina et al. 2012b) evidence propulsion biomechanics differ between people with paraplegia and tetraplegia with the latter group producing lower wrist velocity prior to contact, less magnitude of force impact, and higher radial force.

There is level 4 (from one case series study; Feng et al. 2010) evidence that the movements associated with particular patterns may increase the risk of shoulder impingement, with pumping stroke pattern exposing the shoulder to greater risk than the circular pattern.

There is level 4 (from two case series studies; Kwarciak et al. 2012; Boninger et al. 2002) evidence that the ARC stroke pattern has suboptimal biomechanics, but the lowest muscle demand, therefore holds potential for making it useful for short duration, high force propulsions such during ascending a hill or ramp.

There is level 4 evidence (from two case series studies; Koontz et al. 2009; Richter et al. 2007a) to suggest that the Arc pattern is the most frequently used propulsion pattern used when ascending a slope greater than 3⁰.

There is level 4 evidence (from one case series study; Koontz et al. 2009) to suggest that it takes the first three propulsion strokes from a resting positioning to reach steady state velocity and while the Arc pattern is most frequently used for the first stroke, those who change to an under rim pattern for the subsequent strokes, reach steady state velocities quicker and experience less negative mechanical forces during start up propulsion.

There is level 4 (from one case series study by Koontz et al. 2012) evidence to suggest that when propulsion force and body weight are correlated, propulsion force on a wheelchair dynamometer correlates to propulsion force on a smooth level surface such as a tile floor.

There is level 4 evidence (from one post-test study, Bregman et al. 2009) to suggest that tangential propulsion forces are higher compared to total propulsion forces for people with paraplegic and tetraplegic levels of spinal cord injury as well as for people without a disability.

There is level 4 evidence (from one pre-post study, Russell et al. 2015) that suggests that the forces at the shoulder during fast propulsion are dependent on the forces around the centre of mass at the forearm and upper arm and therefore the position of the upper extremity during the propulsion cycle has a significant effect on shoulder forces.

There is level 5 evidence (from one observational study, Dallmeijer et al. 1998) to suggest that there are differences in the efficiency of force application at the hand rim between participants with paraplegia and tetraplegia which are a result of differences in available muscle movement/function; force application at the hand rim contributes to a large degree to overall propulsion mechanical efficiency.

There is level 4 evidence (from one repeated measures study by Mercer et al. 2006) that higher body mass increases shoulder forces and moments, therefore may be associated with a higher risk of propulsion related injuries.

There is level 4 evidence (from one repeated measures study by Yang et al 2012) that back rest height influences range of motion used for propulsion, cadence and length of stroke used during propulsion.

There is level 4 evidence (from two repeated measures studies by Yang et al. 2012 and Raina et al. 2012a) that to propel up a slope cadence increases and a greater range of motion is used at the shoulder and scapula.

There is level 4 evidence (from one descriptive study by Julien et al. 2013) that trunk and neck flexion increase significantly during the push phase of manual wheelchair propulsion for people with tetraplegia.

There is level 2 evidence (one prospective controlled trial, Kim et al. 2015a) that indicates the sternocleidomastoid muscle is more active during propulsion in people with thoracic level paraplegia than in non-disabled people.

There is level 5 evidence (two observational studies by Mulroy et al. 1996 and VanLandewijck et al. 1994) to suggest that different muscles are primarily active in the push phase than in the recovery phase and that the onset of the different muscle activity does not coincide with the start of each phase.

There is level 5 evidence (from one observational study, Jayaraman et al. 2015) to suggest that the change in directions during the recovery phase of propulsion result in high forces at the shoulder, (termed jerk) and varies by the type of stroke pattern used and the presence of shoulder pain.

There is level 4 evidence (from one prospective study by Gil-Agudo et al. 2010) that the predominant shoulder force during the recovery phase is anterior and is greater than the posterior force exhibited in the push phase of propulsion.

There is level 4 evidence (from one pre-post study, Gil-Adugo et al. 2014) to suggest that both stretching and strengthening of the shoulder muscles and training for optimal wheelchair propulsion techniques are needed as part of rehabilitation.

There is level 4 evidence (from one case series study; Richter et al. 2007b) that wheeling cross slope results in increased loading on users’ arms and may lead to overuse injuries.

There is level 4 (from one case series study by Nagy et al. 2012) evidence that advanced wheelchair skills require greater peak forces at the hand rim, however there is level 4 (from one cross sectional repeated measures study by LaLumiere et al. 2013b) evidence that wheelies require a mean peak hand rim force similar to that of wheelchair propulsion.

There is level 4 (from one cross sectional repeated measures study by LaLumiere et al 2013a)) evidence that ascending curbs of increasing height increases the mechanical and muscular demands at the shoulder and elbow joints placing these joints at risk of injury especially if adequate strength in the associated muscles is not present.

There is level 4 (one case series study by Morrow et al. 2010) evidence that the daily life and mobility activities of weight relief, ramp propulsion and the start phase of propulsion place the larger estimated loads on the shoulder and use greater shoulder abduction and extension moments compared to level propulsion.

There is level 2 evidence (from one prospective controlled study; Bednarczky & Sanderson, 1995) that adding 5-10 kg to the weight of a particular wheelchair will not affect the wheeling style under level wheeling, low speed conditions.

There is level 4 evidence (from two pre-post studies; Beekman et al. 1999 and Parzaile 1991) that the use of lighter weight wheelchairs result in improved propulsion efficiency for those with SCI particularly at the start of propulsion.

There is level 4 evidence (from two case series studies; Boninger et al. 1999; Collinger et al. 2008) that user weight is directly related to pushrim forces, the risk of median nerve injury and the prevalence of shoulder pain and injury.

There is level 2 evidence (from one randomized controlled trial; Vorrink et al. 2008) that the use of Spinergy wheels verses standard steel-spoked wheels was no more effective in reducing spasticity by absorbing vibration forces when wheeling.

There is level 4 evidence (from one post-test study; Garcia-Mendez e t al. 2013) to suggest that whole body vibration exposure for people who use manual wheelchairs are within or above the health caution zone established by ISO.

There is level 4 evidence (from one repeated measures study; Sawatzky et al. 2005) that tire pressure effects energy expenditure only after the tire has been deflated by 50%.

There is level 4 evidence (from one pre-post study; Richter et al. 2005 and one case series study; Richter et al. 2006) that a flexible or compliant hand rim can reduce impact forces and reduce wrist and finger flexor activity during wheelchair propulsion.

There is level 4 evidence (from one pre-post study; Richter et al. 2005; and one observational study; Dieruf et al. 2008) that contoured or flexible hand rims are found to be acceptable to people who propel manual wheelchairs, with perceived benefits of comfort, reduced upper extremity pain and improved propulsion.

There is level 4 evidence (from one repeated measures study; Corfman et al. 2003) that the use of a PAPAW will reduce upper extremity ROM in individuals with paraplegia during wheelchair propulsion.

There is level 4 evidence (from one repeated measures study; Cooper et al. 2001) that the use of a PAPAW may reduce metabolic energy costs for individuals with paraplegia during propulsion and has higher ergonomic rating by users.

There is level 4 evidence (from one pre-post study; Algood et al. 2004) that the PAPAW reduces upper extremity ROM in individuals with tetraplegia during wheelchair propulsion. Metabolic energy expenditure and stroke frequency may be reduced.

There is level 1b evidence (from one randomized controlled trial; Nash et al. 2008) that the use of PAPAW allows individuals with a spinal cord injury (paraplegia and tetraplegia levels) who have long standing shoulder pain to propel their wheelchair further while decreasing energy costs and perceived exertion.

There is level 1b evidence (from one randomized controlled trial; Giesbrecht et al. 2009) that for individuals requiring power mobility, the pushrim-activated, power assisted wheelchair may provide an alternative to power wheelchair use.

There is level 2 evidence (from one non-blinded RCT; van der Scheer et al. 2015) to suggest that training programs of low intensity (two 30 minute sessions per week) of only treadmill propulsion may not affect change in wheelchair propulsion for people who have used wheelchairs long term.

There is level 5 evidence (from one observational study; Hatchett et al. 2009) that suggests that shoulder strength is a strong predictor for average daily distance propelled, and that there are differences in shoulder strength with women’s strength being lower than men’s.

There is level 5 evidence (from two observational studies; Cooper et al. 2011 and Oyster et al. 2011) to suggest that of the cumulative time spent in a wheelchair over the course of a day, a small proportion is spent propelling distances, typically just over an hour a day.

There is level 4 evidence (from one case series study; Tsai et al. 2014) to suggest that the type of wheelchair used is not correlated with social participation.

There is level 4 evidence (from one longitudinal prospective cohort study; Neslon et al. 2010 and two observational studies; Saunders and Krause, 2015 and Chen et al. 2011) which suggests that tipping or falling from the wheelchair is the most frequently experienced wheelchair-use related accident.

There is level 4 evidence (from one longitudinal prospective cohort study; Nelson et al. (2010) and one observational study; Chen et al. 2011) to suggest that there are a variety of predictive factors for wheelchair related falls and injuries including a recent increase in pain, recent history of falls, not using seat belts, lack of regular maintenance, the w/c not being professionally prescribed, high FIM scores on the motor subscale combined with a shorter w/c frame length and a lack of accessibility at home entrance.

There is level 5 evidence (from one cross sectional study by de Groot et al 2011 and one observational study; Fitzgerald et al. 2005) that satisfaction with wheelchair-related service delivery is lower than satisfaction with wheelchair use, primarily due to the slowness of the process, and less so with regards to repairs/service, professional services and follow up services.

There is level 5 evidence (from one observational study, Rushton et al. 2012; and one observational study by Chan & Chan 2007) suggesting that wheelchair satisfaction is more highly focused on quality of life variables such as participation in leisure activities.

There is level 2 evidence (from one RCT study; Wang et al. 2015) that video feedback during training produced similar results as conventional training

There is level 5 evidence (from one observational study; Kilkens et al. 2005c) that wheelchair skills improve from admission to three months post admission to discharge among inpatients in rehabilitation.

There is level 5 evidence (from two cross sectional studies; Lemay et al. 2012, Oyster et al. 2012) that advanced skills primarily associated with wheelie skills (e.g., ascending/descending a 15 cm curb or stairs, maintaining a stationary or moving wheelie position) are not learned by the majority of people who use manual wheelchairs.

There is level 5 evidence (from one cross sectional study; Fliess-Douer et al. 2012 and one qualitative study; Morgan et al. 2015) that the wheelchair skills that are essential for daily life functioning are a mix of basic and advanced skills, including negotiating curbs, ramps and rough terrain and propelling forward at least 50 meters.

There is level 5 evidence (from one observational study; Taylor et al. 2015) that the most frequent skills taught among manual wheelchair users are propulsion, wheelies and curbs.

There is level 4 evidence (from one pre-post study; Van Velzen et al. 2012 and one cross sectional post-test; Hosseini et al. 2012) that higher wheelchair skills in addition to higher peak aerobic power output, lower skill performance time and lower physical strain are associated with increased quality of life, and the likelihood of returning to work five years after SCI.

There is level 5 evidence (Kilkens et al. 2005a) that Wheelchair Circuit variables (ability, time and strain) are associated with the impact of disability on physical and emotional functioning.

There is level 5 evidence (from one observational study; Hunt et al. 2004) that to meet full mobility needs, a wide variety of mobility devices are often used in conjunction with power wheelchairs.

There is level 5 evidence (from one observational study; Biering-Sorensen et al. 2004) that neurological level alone is not indicative of power versus manual wheelchair use.

There is level 5 evidence (from one observational study; Sonenblum et al. 2008) that there are no typical patterns of power wheelchair use in daily life but small bouts of movement were more frequently used.

There is level 5 evidence (from one observational study; Cooper et al. 2002) that power wheelchair users drive at high speeds for most movements but typically for short distances.

There is level 5 evidence (from one observation study; Daveler et al. 2015) to suggest that there are differences in how different power wheelchair drive wheel configurations are perceived to perform in commonly encountered driving situations which require climbing and/or traction control such as uneven terrain, curb cuts, gravel, and mud.

There is level 4 evidence (from one repeated measures study by Lin et al. 2013) that a bimanual power wheelchair controller may be an alternative to a power add on for manual wheelchairs.

There is level 2 evidence (from two prospective controlled trials; Kim et al. 2015b; Kim et al. 2013, one pre-post study by Kim et al. 2014, and one post study by Laumann et al. 2015) that the use of a tongue drive system is demonstrating effective and proficient performance in operating of a power wheelchair and other assistive technology devices.

There is level 5 evidence (one observational study, one descriptive study; Sonenblum et al. 2009, Sonenblum & Sprigle, 2011b) suggesting that on a daily basis, power positioning devices are used for a variety of reasons but predominantly in the small ranges of amplitude, and with great variability of frequency and duration.

There is level 4 evidence (from one post-test study; Sawatzky et al. 2007) that a series of short duration training sessions enables individuals with limited walking ability to safely operate a Segway Personal Transporter.

There is level 4 evidence from one post-test study; Sawatzky et al. 2009) that use of a Segway Personal Transporter does not decrease the time required to complete an obstacle course compared to other mobility devices.

There is level 5 evidence (from one observational study; Taule, et al. 2013) to suggest that pressure mapping can be used to augment clinical decision-making related to pressure management.

There is level 2 evidence (from one prospective controlled trial; Shields & Cook 1992) that the use of lumbar supports does not affect buttock pressure.

There is level 3 evidence (from one case control study; Janssen-Potten et al. 2001) that there is no difference in balance and postural muscle control between static positions on a level surface and a 10° forward incline for people with SCI; the pelvic position does not change as compared to able-bodied participants.

There is level 3 evidence (from three repeated measures studies and one case control study; May et al. 2004; Hastings et al. 2003; Sprigle et al. 2003; Janssen-Potten et al. 2002) to support the evaluation of functional performance to facilitate the decision making process for assessment and prescription of wheelchair and seating equipment options providing objective information about performance.

There is level 2 evidence (from one prospective controlled trial and one case control study; Kamper et al. 1999; Janssen-Potten et al. 2000) to support that pelvic positioning especially related to pelvic tilt and the relationship between the pelvis on the trunk, affects upper extremity and reaching activities, performance of activities of daily living and postural stability.

There is level 4 evidence (from one post study; Wu et al. 2015) that alternating pressure air cushions have good patient satisfaction and comfort.

There is level 5 evidence (from two observational studies; Kovindha et al. 2015, McClure et al. 2014) that over half of the chronic SCI wheelchair users will have a pressure ulcer at some point during their recovery. Those with pressure ulcers are prone to being more depressed.

There is level 2 evidence (from one randomized controlled trial and several supporting studies; Gil-Agudo et al. 2009) to support the air cushion as producing low average ischial tuberosity pressures and a large area for pressure distribution. However, not all cushions have been studied and pressure performance is not the only parameter for consideration in cushion selection.

There is level 2 evidence (from two prospective controlled trials and two repeated measures studies; Li et al. 2014; Sprigle et al. 1990a; Sprigle et al. 1990b; Brienza & Karg 1998) to support that custom contoured cushions (CCC) have attributes that promote their use as a safe sitting surface for the SCI population. In particular, their ability to redistribute interface pressure. However, disadvantages and cautions are identified for the actual use of CCC.

There is level 4 evidence (from one post-test; Kernozek & Lewin 1998) to support that dynamic peak pressures are greater than static but the cumulative loading is comparable between dynamic and static loading.

There is level 2 evidence (from one prospective controlled trial; Tam et al. 2003) to support that peak pressures are located slightly anterior to the ischial tuberosities (IT).

There is level 4 evidence (from one pre-post study; Stinson et al. 2013) to support the use and incorporation of forward reaching into daily activities as a means to promote pressure redistribution, provided the reach distance is adequate for an effective weight shift.

There is level 5 evidence (from one observational study; Yang et al. 2009) to suggest that that the frequency of weight shift behaviour is on average less than one per hour, tending towards long periods of time with no weight shifting.

There is level 4 evidence (one pre-post study Makhsous et al. 2007, one repeated measures Maurer & Sprigle, 2004) to suggest the back support plays an important role in supporting the pelvis thereby increasing the area for pressure redistribution through the inclusion of the back surface.

There is level 4 evidence (one pre-post study and one repeated measures study; Makhsous et al. 2007; Maurer & Sprigle 2004) that sitting surface interface pressure decreases at the posterior aspect of the buttock as it is un-weighted however there is an increase in total force on the seat.

There is level 4 evidence (one post-test, Hobson 1992) to suggest that back support recline to 120° decreases average maximum pressure in the ischial tuberosity area but also causes the greatest ischial tuberosity shift (up to 6 cm) and a 25% increase in tangentially induced shear forces.

There is level 4 evidence (one post-test Hobson 1992, two repeated measures case series study Henderson 1994 and Giesbrecht 2011, one pre-post study Spijkerman 1995, and one observational study Sonenblum & Sprigle 2011a) suggesting that there is an inverse relationship between tilt angle and pressure at the sitting surface and that significant reductions in interface pressure begins around 30° of tilt with maximum tilt providing maximum reduction of interface pressures. The amount of reduction realized was variable by person.

There is level 4 evidence (from two repeated measures studies, one pre-post study, and one observational study; Jan et al. 2010; Jan et al. 2013a; Jan & Crane 2013) to suggest that larger amounts of tilt alone or 15° tilt and greater in combination with 100° or 120° recline result in increased blood flow and decreased interface pressure at the ischial tuberosities (IT). There is inconsistency in the minimum amount of tilt needed to significantly increase both blood flow and interface pressure reduction. There is also limited evidence related to impact of shear forces with use of recline.

There is level 4 evidence (from one repeated measure study and one observational study; Jan et al. 2013b; Sonenblum & Sprigle 2011a) to suggest that it cannot be assumed that changes in interface pressure through use of recline and/or tilt equates to an increase in blood flow at the IT or the sacrum.

There is level 4 evidence (from one repeated measure study and one observational study; Jan et al. 2013b; Sonenblum & Sprigle 2011a) to suggest that muscle perfusion requires greater amplitudes of body position changes than that required for skin perfusion.

There is level 5 evidence (from one observational study: Yang et al. 2014) that the forces at the knee, the range of sliding and displacement along the seat and the back differ significantly between the sit-to-stand and the stand-to-sit phases.

There is level 4 evidence (from one pre-post study; Lung et al. 2014) to suggest that peak pressure index, which is a common metric used in interface pressure mapping, displaces up to almost 7 cm during tilt and/or recline, therefore consideration for the size of the sensel window used to capture this data should either be large enough (7×7) or the location adjusted to ensure the data is fully captured.

There is low-level evidence about wheelchair provision among people with spinal cord injury, which includes two pre-post studies which suggest beneficial results from interventions and six descriptive studies.